(Living Will with Durable Power of Attorney for Health Care)

Page 1 InstructionsPage 2 InstructionsPage 3 InstructionsEnd Notes

There are only three requirements for an effective Advance Health Care Directive in most states:   It must be signed, dated and notarized or witnessed. Otherwise, you can put down what you want.  For requirements in various states see Finalization .

Your Advance Health Care Directive should name someone who can make medical decisions for you when you are unable to do so. This person is called your Agent, or sometimes your proxy.   As noted in THINK, this person must be carefully chosen, after you’ve discussed your wishes with her or him (and the alternate agent if you name one).

This form does not mention DNR – Do Not Resuscitate.  Why?  DNRs are designed to be used by patients who have had a serious health episode, and may have another.  In California and some other states, there is a special pink form called a POLST Order (Physician Orders for Life-Sustaining Treatment), which your physician signs.  People often put the POLST on their refrigerator where medics can see it.   There is a POLST bracelet than can be worn.  And thirdly, there can  be times where resuscitation would be in order because it is not caused by your current medical condition.  For example, if resuscitation is necessary because you choked on food.   Discuss with your Agent and your physician whether DNR needs to be in your health plan directive, and/or a POLST order needs to be signed now.  They can always be done later.

Instructions for PAGE  1 of the Advance Health Care Directive Form (each page can be clicked on/viewed below, or go to Fillable Form)

Here you put down the names, phone numbers and addresses of your Agent, your Alternate Agents, and your primary care physician.  The Alternate Agents have authority only if your Primary Agent is unwilling or unable to serve.

Instructions for PAGE  2 of the Advance Health Care Directive Form

This page is the heart of your directive.  It is in three parts: (1) Authority of my Agent, (2) Instructions to my Agent, and (3) Instructions to my Agent and to my Personal and Attending Physicians.  Read the entire page before you make any choices.

Authority of my Agent.  This meets the legal requirement for your agent to speak for you when you can’t speak for yourself.1  The authority is very broad.   It can be narrowed by completing the following provisions, especially the In Addition section.

Instructions to my Agent.  It says you’ve discussed your wishes with your Agent.  It makes clear that the Agent is to do what you would want, not what the Agent would want for herself or himself.   This paragraph contains two options.  First, you may authorize your Agent to override your wishes as stated in the directive. Second, you may wish to have your Agent involved in your health care decisions with you, even before you are not able to make those decisions yourself.

Instructions to my Agent and to my Personal and Attending Physicians.   Here is where you need to make choices that will act as directives to both your Agent and your physicians.  Please note that medical professionals have a duty to keep you alive.   If you want to be kept alive regardless of the circumstances you might be in, then cross out everything that follows the introductory sentence of the Initial All that You Want Applied section down and through sub-paragraph (d).

However, most of us do not want to be kept alive under all circumstances.  If that is your leaning, then you need to choose among the options given, or make your own in the In Addition section on Page 3 of the Form.

First, tell your Agent and Physicians whether or not you want to be kept alive in a vegetative state.  A “vegetative state” is a state in which a previously comatose patient continues to be unable to communicate or respond to stimuli despite at times giving the appearance of wakefulness.2

The next paragraph introduces quality of life as a means of determining health care decisions.

More and more people at the end of their life are choosing to focus on how they might be alive but so miserable that they don’t wish to go on living, and so choose to not go on living.   Since it is quite possible you will not have the ability to decide for yourself when this point is reached, you must make your wishes known to your Agent, and even to your physician, so that they will follow your wishes even though you can’t communicate them.

The form does not give choices as to what the minimum quality of life is.3  The minimum desired quality will vary greatly from person to person.  But you have discussed quality of life with you Agent (haven’t you?).  Be sure your Agent agrees to abide by your wishes as to the quality of life you want or don’t want, even if the Agent would choose otherwise for himself or herself.    You are given the option to write down what that minimum quality of life is for you in the IN ADDITION section. One approach to quality of life is to ask the question, “Would more days of life in this condition be a gift and a blessing, or a burden and an unwanted imposition?”   Minimum quality might be: You want to be able to recognize and converse with your family; You want to be able to remember yesterday, or what was said an hour ago; You want to be able to get out of bed and walk on your own.   This is a very personal matter, and it deserves much thought on your part, and discussion with your Agent.  More suggestions are given in end note 4.

The form gives four choice points at which you are no longer to be kept alive because it is quite unlikely you will be able ever to achieve the minimum quality of life you wish.  Each is more severe than the preceding one.  They are:

  1. Discontinue the medical treatments that are keeping you alive.
  2. You don’t wish to be kept alive by feeding you artificially through an IV or tubes in your throat.
  3. You don’t want to be forced to eat or to drink by someone pushing food or water in your mouth.
  4. You don’t want food or water in any form: you want to end your life the shortest yet legal way possible.  If, as to d), refusing all food and fluid, you want to learn more about this rather radical decision, read Dr. Terman’s book in References.   In the states of Oregon, Washington, Montana and Vermont, you have another option, which is physician assistance.

Instructions for PAGE  3 of the Advance Health Care Directive Form

The IN ADDITION section can be left blank or used for anything you wish.  You might want to put down the qualities of life you want or don’t want, or the foods you like or you don’t like.  Alternatively such things can be put down in special letter of instruction to your Agent.  Such a separate instruction is recommended by others, and is often a good idea, depending on your circumstances.

Also in the IN ADDITION section, you can restrict, add to, or otherwise change anything you’ve chosen on page 2.  Also, as already noted, you can put down that minimum quality of life you wish to have, or the life you don’t want (see the last end note below).  If these wishes can’t be achieved, then the options you’ve chosen in (a) through (d) kick in.

Note also that you may choose to cross out some portion of an option or a sentence.  That’s easier than writing out the change. But if you do a cross out, be sure to initial it.   Further, if there is not enough space for what you want to write, use an extra page.  Be sure to mention the extra page, and be sure the extra page references the particular place in your directive it is linked to and is signed and dated the same day as your directive.

In the AT HOME section you may choose to stay or return home.   Being at home at the end is important to many people, not just because of the familiar surroundings, but also because it is so much easier to have your family around you.

Note, as written, the second sentence says that the AT HOME instruction is not to override anything chosen earlier.  You might want to cross this sentence out if being at home is that important to you.

In the AFTER DEATH WISHES section, you may authorize your agent to have an autopsy done, direct the disposition of your remains, and donate your organs.

In the SIGNATURE section, you date and sign.  But, do NOT do so until you have a notary or two witnesses before you, as your state may require.  If you have both witnesses and a notary, sign before your witnesses.  Any notary can do the acknowledgement needed.4  If you choose witnesses, a few types of people are restricted from being a witness.  See Finalization for more detail on all of this.  Click on each page below to see an enlarged view of the form.  Click here to download a fillable form, with or without the instructions.



  1. Technically this a durable power of attorney for health care.
  2. There is no mention of the possibility that you may be somewhat conscious, but still in a vegetative state.   There are legal complications when the terms consciousness, unconsciousness or semi-consciousness are used.
  3. Here are some possibilities to consider.  Not being able to: control my bowls and bladder (incontinence); get out of bed; clean myself; walk to and use the bathroom; carry on an intelligent conversation; understand what is going on around me; feed myself; eat whole food (i.e., having to eat pureed/baby food); remember what I’ve done today, or a few moments ago; walk or sit outside.
  4. You can tell the notary it is your signature, or re-sign in front the Notary too, as the notary may require


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